access to abdomen in laparoscopy

1. Access to Abdomen
By DR Amin abtahian fellowship of laparoscopic surgery
Shiraz university of medical science

2. Equipment
I. Insufflator
II. Veress needle

3. Insufflator
I. Check the insufflator to assure that it is functioning properly
II. Connect the sterile insufflation tubing (with in-line filter) to the
insufflator.
III. Turn the insufflator to high flow (>6 L/min); with the insufflator
tubing not yet connected to a Veress needle, the intra-
abdominal pressure indicator should register
IV. Lower the insufflator flow rate to 1 L/min. Kink the tubing to
shut off the flow of gas. The pressure indicator should rapidly
rise to 30 mmHg and flow indicator should go to zero

4. • Next, test the flow regulator at low and high inflow. With the
insufflator tubing connected to the insufflator and the Veress
needle (before abdominal insertion), low flow should register 1
L/min and at high flow should register 2–2.5 L/min; measured
pressure at both settings should be less than 3 mmHg. A
pressure reading 3 mmHg or higher indicates a blockage in the
insufflator tubing or the hub or shaft of the Veress needle
• Maximal flow through a Veress needle is only about 2.5 L/min,
regardless of the insufflator setting because it is only 14 gauge.
• A Hasson cannula has a much larger internal diameter and can
immediately accommodate the maximum flow rate of most
insufflators (i.e., >6 L/min)

5. • During most laparoscopic procedures, the
pressure limit should be set at 12–15 mmHg;
intra-abdominal pressures higher than this
limit can diminish visceral perfusion and
venacaval return, but may be required in
obese individuals to achieve adequate
visualization.

6. Veress Needle
• The former is a one-piece plastic design (external diameter, 2 mm; 14
gauge; length, 70 or 120 mm), whereas the latter is made of metal and can
be disassembled.
• Check the Veress needle for patency

7. Closed” Technique with Veress Needle
I. Umbilical Puncture :
Place the supine patient in a 10–20° head-down position
If there are no scars on the abdomen, choose a site of entry at
the superior or inferior border of the umbilical ring.
Immobilize the umbilicus and provide resistance to the needle.
Next, make a stab incision in the midline of the superior or inferior
margin of the umbilicus. With the dominant hand, grasp the shaft
(not the hub) of the Veress needle like a dart and gently pass the
needle into the incision—either at a 45° caudal angle to the
abdominal wall (in the asthenic or minimally obese patient) or
perpendicular to the abdominal wall in the markedly obese patient.

8. • There will be a sensation of initial resistance, followed by a give, at
two points. The fi rst point occurs as the needle meets and traverses
the fascia and the second as it touches and traverses the
peritoneum.
• Connect a 10-mL syringe containing 5 mL of saline to the Veress
needle. There are fi ve tests that should be performed in sequence to
confi rm proper placement of the needle.

9. I. Aspirate to assess whether any blood, bowel contents, or
urine enter the barrel of the syringe.
II. Instill 5 mL of saline, which should flow into the
abdominal cavity without resistance.
III. Aspirate again. If the peritoneal cavity has truly been
reached, no saline should return.
IV. Close the stopcock and disconnect the syringe from the
Veress needle, then open the stopcock and observe as
any fl uid left in the hub of the syringe falls rapidly into
the abdominal cavity (especially if the abdominal wall is
elevated slightly manually). This is the so-called drop
test. If free fl ow is not present, the needle either is not in
the abdominal cavity, or it is adjacent to a structure

10. • Finally, if the needle truly lies in the peritoneal cavity, it
should be possible to advance it 1–2 cm deeper into the
peritoneal cavity without encountering any resistance.
Specifi cally, the tip indicator or the hub of the needle
should show no sign that the blunt tip of the needle is
retracting, thereby indicating the absence of fascial or
peritoneal resistance. Similarly, resistance to the needle tip
may be caused by impingement on intraabdominal viscera
or adhesions.
• Always be cognizant of anatomic landmarks when placing
the needle, and carefully stabilize the needle during insuffl
ation. Minimize sideto-side and back-and-forth movements
of the needle to avoid inadvertent injuries.

11. • After ascertaining that the tip of the Veress needle lies freely in
the peritoneal cavity, connect the insuffl ation line to the Veress
needle. Turn the fl ow of CO 2 to 1 L/min, and reset the indicator
on the machine for total CO 2 infused to 0. The pressure in the
abdomen during initial insuffl ation should always register less
than 10 mmHg.
• If high pressures are noted or if there is no fl ow because the 15
mmHg limit has been reached, gently rotate the needle to
assess whether the opening in the shaft of the needle is resting
against the abdominal wall, the omentum, or the bowel. The
opening is on the same side of the needle as the stopcock. If
the abdominal pressure remains high (i.e., needle in adhesion,
omentum, or preperitoneal space), withdraw the needle and
make another pass of the Veress needle

12. • repeat this process several times until you are certain that
the needle resides within the peritoneal cavity. Do not
continue insufflation if you are uncertain about the
appropriate intraperitoneal location of the tip of the Veress
needle. Multiple passes with the Veress needle are not
problematic, provided the error is not compounded by
insufflatin7g the “wrong” space.
• One of the first signs that the Veress needle lies freely in
the abdomen is loss of the dullness to percussion over the
liver during early insufflation.
• if CO 2 bubbles out along the needle’s shaft during
insufflation, suspect a preperitoneal location of the needle
tip.

13. • Monitor the patient’s pulse and blood pressure closely for a
vagal reaction during the early phase of insufflation. If the
pulse falls precipitously, allow the CO 2 to escape,
administer atropine, and reinstitute insufflation slowly after
a normal heart rate has returned.
• After 1 L of CO 2 has been insufflated uneventfully,
increase the fl ow rate on the insufflator to 3-6 L/min When
the 15 mmHg limit is reached, the flow of CO 2 will be cut
off. At this point, approximately 3–6 L of CO 2 should have
been instilled into the abdomen When percussed, the
abdomen should sound as though you are thumping a ripe
watermelon.

15. • Drop test (Epidural space test):
- a drop of water --- suctioned into
peritoneal cavity
• Syringe barrel flow test:
• Manometer test (free flow of gas):
- elevation of abdominal wall, falling
insufflation pressure ( < 5-6 mmHg at
1.0L/min flow )
• Loss of liver dullness early in insufflation

16. • Aspiration-instillation-aspiration test (Syringe aspiration test):
- Aspiration : blood, bile, bowel content, urine
- Instillation : 10cc N/S--- if any resistant
- Re-aspiration : no fluid aspirated
• Waggling test (Lateral needle swing test): (potentially
dangerous)
- base on tactile confirmation of a free-
moving tip
- pivot point at the tip --- adhesion or pre-
peritoneal
- pivot point at the fascia --- intraperitoneal

17. Alternate Puncture Sites
• Prior abdominal surgery mandates care in selection of the
initial trocar site, and may prompt consideration of use of
the open technique.
• If the previous incisions are well away from the umbilicus,
the umbilical site may still be used, with either a closed or
open technique.
• lateral to the rectus muscles.
• In general, patients with prior low vertical midline scars
should be approached through a trocar placed at the lateral
border of the rectus muscle in either the left or right upper
quadrant.

18. • With previous upper vertical midline incision or multiple incisions
near the midline, the right lower quadrant site may be appropriate.
Alternatively, it is possible to perform an open technique with the
Hasson cannula.
• Upper abdomen. In the upper abdomen, the subcostal regions are
good choices. Carefully percuss the positions of the liver and spleen
to avoid inadvertent injury to these organs, and decompress the
stomach with a nasogastric or orogastric tube.
• Lower abdomen. The right lower quadrant, near McBurney’s
point, is preferable to the left because many individuals have
congenital adhesions between the sigmoid colon and anterior
abdominal wall. Decompress the bladder when using a closed
insertion technique at, or caudad to, the umbilicus.

19. Placement of Trocar
• Always inspect the trocar to ensure that all valves move
smoothly, that the insuffl ation valve is closed (to avoid
losing pneumoperitoneum), and that any safety shields
work properly. Make sure that you are familiar with the
trocar; with the variety of designs available, it is not
uncommon to be handed a different device.
• Once you have attained a full pneumoperitoneum, remove
the Veress needle.
• In a slender individual, the distance to the viscera and
retroperitoneal structures is slight, and it is prudent to aim
the trocar down into the pelvis. In an obese patient, this is
less a problem and the trocar may be passed in a more
direct path.

20. • Patient in a horizontal position
• Skin incision should be large enough to prevent any resistance
• A stretched middle finger can prevent over-insertion (palming
technique)
• Z-technique (prevention of incision hernia)

21. Z-technique

23. Open” Technique with Hasson Cannula
• The open (e.g., Hasson 1971 ) cannula provides the
surgeon with an alternative, extremely safe method to enter
the abdomen, especially in a patient who has previously
undergone intra-abdominal procedures.
• The open cannula consists of three pieces: a cone-shaped
sleeve, a metal or plastic sheath with a trumpet or flap
valve, and a blunt-tipped obturator .
• Make a 2–3-cm transverse incision at the selected entry
site (in the quadrant of the abdomen farthest away from
any of the preexisting abdominal scars or in the
periumbilical skin crease if there has been no prior midline
surgery).

24. Hasson cannula

25. • Dissect the subcutaneous tissue with scissors, and identify and incise
the underlying fascia Exposure is usually facilitated by the use of small
L - or S -shaped retractors. Gently sweep the preperitoneal fat off the
peritoneum in a very limited area. Grasp the peritoneum between
hemostats and open sharply. This incision should be just long enough
to admit the surgeon’s index finger .

27. Avoiding, Recognizing, and Managing
Complications
1. Bleeding from abdominal wall :
a. Cause and prevention: This problem usually manifests itself as a
continuous stream of blood dripping from one of the trocars, and/or as blood
seen on the surface of the abdominal viscera or omentum. Less commonly,
delayed presentation as a hematoma of the abdominal wall or rectus sheath
may occur.
This source of bleeding is usually the inferior epigastric artery or one
of its branches
a. Recognition and management : To determine the point at
which the vessel is injured, cantilever the trocar into each of four
quadrants until the flow of blood is noted to stop.

29. Visceral injury
I. Cause and prevention : Careful observation of the steps just
enumerated will minimize the chance of visceral injury. However,
placement of the Veress needle is a blind maneuver, and even with
extreme care puncture of a hollow viscus is still possible.
II. Recognition and management : If aspiration of the Veress
needle returns yellowish or cloudy fl uid, the needle is likely in the
lumen of the bowel. Due to the small caliber of the needle itself,
this is usually a harmless situation. Simply remove the needle and
repuncture the abdominal wall.
After successful insertion of the laparoscope, examine the abdominal
viscera closely for signifi cant injury.

30. Major vascular injury
I. Cause and prevention :Major vascular injury can occur when
the sharp tip of the Veress needle or the trocar nicks or lacerates a
mesenteric or retroperitoneal vessel. It is rare when the open
(Hasson cannula) technique is used .
II. Recognition and management : If there is a central or
expanding retroperitoneal hematoma, laparotomy with
retroperitoneal exploration is mandatory to assess for and repair
major vascular injury.

31. • On removal of a laparoscope. Check by direct visualisation
that there has not been a through-and-through injury of
bowel adherent under the umbilicus
• Secondary ports must be removed under direct vision to
ensure that any haemorrhage can be observed and treated,
if present.

32. Generation of Working Space:
Extraperitoneal Approaches
was first described by Bartel in 1969. Wickham and Miller
described the use of carbon dioxide (CO 2 ) and videoscopic
control in 1993 while performing a ureterolithotomy. The initial
difficulties using this approach mainly related to inability to create
a sufficient pneumoretroperitoneum. Gaur introduced balloons for
retroperitoneal dissection in 1993, and Hirsch and coworkers
described the use of a trocar mounted balloon for extraperitoneal
dissection in 1994.

33. • Today, the EES is most commonly utilized for totally
extraperitoneal (TEP) inguinal herniorrhaphy .
• There are both advantages and disadvantages to this approach .

35. Anatomic Considerations
I. Preperitoneal space—between the transversalis fascia and parietal
peritoneum of anterior abdominal wall. The inferolateral border
includes the space of Bogros which is lateral to the epigastric
vessels and dissected in the TEP inguinal herniorrhaphy.
II. Retroperitoneal space—containing the aorta, vena cava, and the
retroperitoneal organs.
III. Subperitoneal space—surrounds the pelvic organs anteriorly
beginning at the space of Retzius between the pubic bone and the
bladder and posteriorly with the pararectal spaces.
IV. The lumbar retroperitoneal space is the posterior continuation of
the space of Bogros bounded by the vena cava and aorta medially,
the psoas dorsally, the colon ventrally, and transversalis fascia
laterally. This space contains the kidney, adrenal, ureter, and
Gerota’s fascia .

38. Access to the Extraperitoneal Space
• Depending on the type of procedure, the patient is either
placed in supine or lateral decubitus position. There are
three basic ways to gain access to the extraperitoneal
space.
• For TEP approach, the incision is typically periumbilical, on
the opposite side of the hernia. For access to
retroperitoneal organs, the incision is usually 2 cm above
iliac crest in posterior axillary line.

39. The open approach
Make a 2-cm incision overlying the space to be developed.
Bluntly dissect down to the preperitoneal space and
develop this space.
Place a Hasson cannula or a structural balloon trocar
Continue dissection with laparoscope or balloon dissector

40. Use of a lens-tipped trocar
Make a 12-mm skin incision over the desired location.
Place a 0° laparoscope into a lens-tipped trocar.
Use this to penetrate the layers of the abdominal wall
under direct vision.
Once the correct plane is achieved, place a Hasson
cannula or structural balloon trocar and continue
dissection

41. The closed approach using the Veress needle
• Insert a Veress needle suprapubically through the fascial layers into
the preperitoneal position. The needle will traverse two palpable
points of resistance (the anterior rectus sheath and transversalis
fascia).
• Insuffl ate 1 L of CO 2 .
• Make a skin incision lateral to the midline.
• Insert a 10-mm trocar, directed caudad, until the gas-fi lled space is
entered.
• Place the laparoscope into the trocar and use it to dissect the space
while insufflating CO 2 .
• The major disadvantage is that this procedure is relatively “blind” and
risks visceral and vascular injury as well as penetration of the
peritoneum. If this technique is used to develop the lumbar
retroperitoneal space, fl uoroscopic control with ureteral and nephric
imaging is essential.

42. Dissection of Extraperitoneal Space
• Operating laparoscopes have a 5-mm instrument channel (in a 10-mm
laparoscope). These allow dissection under direct vision during
insufflation of CO 2 .
• Alternatively, a 30° laparoscope can be used alone to open the space
by sweeping tissue away while insufflating CO 2 .
• Balloon dissection is the most popular, if most expensive, method of
developing the extraperitoneal space. It may be beneficial,
particularly early in the surgeon’s experience with this procedure.

43. Maintenance of Extraperitoneal Space
• Insufflation to 8–10 mmHg CO 2 will maintain a working space while
avoiding excessive subcutaneous emphysema.
• Planar abdominal wall-lifting devices, allow gasless extraperitoneal
endoscopy using conventional instruments.
• In TEP hernia repairs, the structural balloon trocar replaces a Hasson
cannula and displaces peritoneum posteriorly while providing a seal
between skin and fascia and providing access for the laparoscope.
• Peritoneal retraction devices are necessary to displace the peritoneal
sac for lumbar and iliac extraperitoneal laparoscopy. These
instruments can be used in a gasless or gas extraperitoneal
laparoscopic procedure.

44. Potential Problems
• Penetration into the peritoneal cavity
• Peritoneal holes
• Venous bleeding
Prior retroperitoneal dissection obliterates the potential
space and is a contraindication to the extraperitoneal
approach.
• This procedure is more difficult in obese patients , as
excess adipose tissue in the extraperitoneal space will
obscure planes and landmarks.